Prevalence and factors associated with malnutrition

in children aged 6-59 months in Jubek State, South

Sudan.
Martin Adelino Iyya  (  ohureomoi@gmail.com )
Makerere University https://orcid.org/0000-0001-9674-5506
Ndeezi Grace 
Makerere University College of HealthSciences School of Medicine
Nabukeera Barungi Nicolette 
Makerere University College of Health Sciences
Hassan Chollong 
University of Juba

Research article

Keywords: Malnutrition, Stunting, factors associated, wasting, underweight, South Sudan, Jubek State

DOI: https://doi.org/10.21203/rs.3.rs-15585/v3

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.  
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Abstract
Background:  South Sudan is the world’s youngest nation which gained independence from Sudan on the
9th of July, 2011. Rates of acute malnutrition have been consistently higher in South Sudan than any
other country in sub-Saharan Africa, according to South Sudan Household Survey 2010, the prevalence of
Global Acute Malnutrition in children under 5 years was 22%, Prevalence of stunting is 45% and
underweight was 48%. This study sought to determine the prevalence and factors associated with
malnutrition among children aged 6-59 months in Jubek state, South Sudan.

Methods: This was a cross sectional analytical community based study to assess the prevalence and
factors associated with malnutrition among children aged 6-59 months in Jubek state, South Sudan.
Data was collected using a structured questionnaire from 396 children. Anthropometric measurements
including weight, length/ height, mid upper arm circumference (MUAC) were taken and a blood sample by
nger prick was removed for HIV test. The equipment which were used included: WHO recommended
MUAC tape for 6months to 59 months old children, digital weighing scale (SECA) and portable
Stadiometers. Data were collected using a pretested semi- structured questionnaire.

Results: The analysis of this study revealed that, 32.2%, 28.2% and 32.3% of children were stunted,
wasted and underweight respectively. The main associated factors of stunting were age older than one
year (p= 0.004), children from households who were renting their houses and children who defecate in
open spaces with no latrine at their homes (p= 0.015). Underweight was associated with child’s age (p=
0.001), loss of appetite (p=<0.001), children who ate from own plate (p=0.001) and children who didn’t
consume meat (p=0.007). Male genders (p=0.022), households with two or more children aged zero to
ve years (0.010) not consuming vitamin A rich vegetable (p=0.002), diarrheal disease within two weeks
prior to interview (p=0.006) and those from households with water sources other than piped (<0.001)
were also associated with wasting.

Conclusion: The general objective of this study was to assess the nutritional status of children aged 6-59
months in Jubek state, South Sudan. This study showed that the levels of stunting, wasting and
underweight were high, one in three children were likely to be stunted (32.1%), or wasted (28.2%) or
underweight (32.3%).

Background
Malnutrition is estimated to contribute to more than one third of all child deaths. Lack of access to highly
nutritious foods, especially in the present context of rising food prices, is a common cause of
malnutrition. Poor feeding practices, such as inadequate breastfeeding, offering the wrong foods, and not
ensuring that the child gets enough nutritious food, contribute to malnutrition. Infection – particularly
frequent or persistent diarrhea, pneumonia, measles and malaria – also undermines a child's nutritional
status (1).

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In the year 2011, 6.9 million children under the age of 5 years died worldwide, one
third of them related to increased susceptibility to illnesses due to under nutrition. An
estimated 178 million children under 5 years are stunted, 55 million are wasted, and 19
million of these are severely affected and are at a higher risk of premature death, the vast
majority being from sub-Saharan Africa and South-Central Asia (2).

Post war areas in the East African region have reported high levels of malnutrition. The level of global
acute malnutrition in Gulu district in Uganda was 6.o%, prevalence of global stunting was found to be
52.4% ,this was similar to another post war area in Kasese district in Uganda which also found a
prevalence of 49.8%  (3) (4).

South Sudan is underdeveloped country with very little basic infrastructure for health systems, safe water,
functioning markets and lack of food security.

Reports from WHO and UNICEF in 2013, under ve years mortality rate is 65% in which neonatal mortality
accounts for 35%  (5). UNICEF South Sudan described the nutrition situation for children in the country as
dire, with over 248,000 children estimated to be suffering from severe acute malnutrition (SAM). This
number rose from 108,000 before the 2013 crisis to 248,000 in 2015 mainly due to deteriorating food
insecurity, displacement and destruction of health, water sanitation facilities along with suboptimal
infant and young child feeding practice (IYCF)  (6).

This study aimed to determine the prevalence and factors associated with malnutrition among children
aged under ve years in Jubek state, South Sudan.

Jubek state was chosen because of increase population secondary to in ux of internally displaced
people, cultural diversity and more secured compared to other states within South Sudan.

Methods
Study area

 This study was carried out in Jubek State located in the Southern part of South Sudan. The state borders
include Yei River State to the south east, Amadi State to the west, Terekeka State to the north and
Imatong State to the east(7). In 2008, Jubek State had a population of about 1.1 million people with 581,
722 males and 521,835 females. Children under the age 18 constitute 49% with 15% of the population
being children under the age of 5 years. It is an urban state where South Sudan’s capital city Juba is
located. It has an area of 43,033 square kilometers.

Jubek State is consisted of 14 counties. Theses counties are further divided into Payams , then Bomas.
Juba is known as the capital of the entire country as well as the capital of Jubek State.

Selection of subjects:

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The study population including all children aged 6-59 months was randomly selected. All children aged 6-
59 months in Jubek State during the study period. Children whose parents/ Caregivers provided written
informed consent

We employed the modi ed WHO cluster sampling technique to select study households and participants.
Households with more than one child aged of 6-59 months were assigned numbers on a dice from the
youngest to oldest by the principal investigator/or research assistant. The research assistant/ Principal
investigator would then roll the dice and the child selected for the interview would be the one whose
number corresponds to the dice number facing upwards after the roll.

Sample size and sampling technique

The sample size calculation for this study was based on (i) the prevalence of malnutrition with a design
effect (DEFF) adjustment because the sampling design used was cluster sampling rather than simple
random sampling, and (ii) association between malnutrition and selected factors, like consumption of
safe drinking. The higher computed size of 396 from the two options was chosen as the study sample
size. 

Variables:

The primary outcome of this study was nutritional status measured by stunting because it is a variable
that measures chronic malnutrition and long term outcomes. Whereas the secondary outcomes were both
wasting and underweight.

The independent variables for this study included: socio-demographic variables, child characteristics;
child caring practices, and environmental health. Information on these independent variables was
collected using a pretested structured questionnaire administered on caretakers of 396 children. Children
were Weighted with minimum clothing, bare feet using a digital SECA scale in kilogram to the nearest of
0.1 kg. whereas their length was taken in a lying position with wooden measuring height board for
children aged less than two years. The height of children aged more than two years was measured in a
standing position in centimeters to the nearest of 1 cm. Information for anthropometric measurements
were collected through measuring of length/height and weight of the selected participants.  WHO growth
charts (2006) were used to convert the anthropometric measures into Z-scores of the indices; Height for
Age(HAZ), Weight-for-Height(WHZ) and Weight-for Age(WAZ).

Measurements for the disease burden

Questionnaire was used to capture information on the disease burden. Questions on presence of any
chronic illness including T.B, HIV, or history of recent diarrhea, fever, and ARI were asked to assess for the
disease burden.

Blood samples for HIV testing were taken for children whose primary care giver consented. We used rapid
ELISA test. This HIV testing was done by the research assistant/ counselor who received training in
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counseling and how to perform HIV test. Children found to be HIV positive were linked to AL-Sabah
Children’s hospital which provides HIV services.

Measurement for household food security

This was assessed using Household Food Insecurity Access Scale (HFIAS) which assess three domains
in the household includes: uncertainty about household access and anxiety, insu cient quality and
quantity of food intake (8)

Questions 24- hour recall on the number, type of foods taken was used to measure for the household
food diversity and frequency.

Analysis

STATA 14.2 statistical software was done for Statistical analyses. we rst analyzed the descriptive
statistics including proportions and frequencies in tables. This was then followed by the bivariate
analyses of the three outcome indicators of malnutrition (stunting, wasting and underweight) each
separately. All variable (independent) in the bivariate analyses with a p- value less than 0.25 were
preliminarily taken for further analyses and diagnostic testing in multivariate analyses. Bivariate and
modeling was done using a logistic modeling to produce both unadjusted and adjusted odds ratios and
their corresponding p-values. Backward elimination technique in logistic modeling was used to identify
the determinants of the three outcomes of malnutrition (wasting, stunting and underweight). Statistical
signi cance was observed where p<0.05 t as statistical measure of association.

Ethics Approval and consent to participate

Permission to carry the study was obtained from the department of pediatrics and child health, Federal
ministry of health South Sudan, Jubek’s state ministry of health and permission from the local
community leaders to carry this study was also sought. Ethics approval was obtained from the Makerere
University School of Medicine Research and Ethics Committee (SOMREC) as well as the Uganda National
Council of Science and Technology. A written informed consent/assent was sought from the caregiver
followed by a full explanation of the study objectives, procedures, risks and bene ts. Care givers were
also informed that they had rights to participate and withdraw out of the study at any time.

Children who were found to be undernourished, were linked to appropriate therapeutic facility.

Results
out of the total of 396 sampled and interviewed study participants, only 393 (99.2%) were analyzed ,
3(Three) withdrew their consent during the interview process. Socio Demographic of the sampled
children, their caretakers and their households are presented in Table 1. A total of 393 children aged 6-59
months in Jubek State were enrolled in the study. There were almost equal numbers of males and
females in the ratio of 1:1. Eighty-eight percent of the participants were Christians (349/393), and most of
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the respondents were mothers (355/393, 90.3%).  Only 86(21.9%) households had ve or less members
and 161(40.9%) of the households had ten or more members. As regards to the economic status of the
caretakers, most of the caretakers were earning more than 1USD (18ssp) per day and only 21/393 (7.8%)
were earning less than 1USD (18ssp) per day. Other socio demographics of the children are shown in
Table 1.

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 Table 1: Demographic factors of children aged 6-59 months and caretakers in Jubek State
enrolled study

Characteristic   Total n
(%)
Sex of Child Male 199(50.6)
  Female 194(49.4)
Age of Child <12 Months 51(13.0)
  ≥12 Months 342(87.0)
Religion of child Christian 349(88.8)
  Others 44(11.2)
Respondent’s details    
     
Age of respondent ≤ 24 Years 110(28.0)
  25 and above 283(72.2)
  Mother 355(90.3)
Relationship to child Father 23(5.9)
  Others 15(3.8)
  Single 3(0.8)
Marital Status of Caretaker Married 341(86.8)
  Cohabiting 31(7.9)
  Widowed 18(4.6)
Level of Education No Formal Education 113(28.8)
  Primary 148(37.7)
Mother to child Secondary& above 132(33.6)
  No Formal Education 45(12.2)
Father to child Primary  61(16.5)
  Secondary& above 263(71.2)
Education
     
Socio-economic characteristics Below 500ssps 21(7.8)
Monthly income of caretaker to child 500-1000ssp 39(14.5)
  1000-5000sspssp 134(49.8)
  Above 5000ssp 75(27.9)
Building type Mud 317(83.4)
  Bricks 63(16.6)
House ownership Rented 193(49.1)
  Owned 200(50.9)
  Yes 35(9.3)
Farmland No 345(90.7)
  > 10 Members 232(59.0)
Household number of people ≥ 10 Members 161(41.0)
  ≤2 Members 251(63.9)
Household members aged 0-5yrs >2 Members 142(36.1)
HH members aged  6-18 years ≤4 Member 342(87.0)
yyarsyears Years
  <4 Members 51(13.0)

Among children enrolled in this study, most 328(83.5%) were fully immunized, but 65(16.5%) children
were not/partially immunized (Table 2). Over four tenth 174(44.3%) of the children had ever been
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diagnosed with pneumonia whereas 13(3.3%) had ever been diagnosed with measles. Other health
related conditions assessed in this study are shown in Table 2.

Table 2: Medical history and clinical characteristics of the participant

Factor TOTAL n (%)
Immunization Status of Child
Fully Immunized 328(83.5)
Not    Immunized 65(16.5)
Child sleep under mosquito net
Yes 343(87.3)
No 50(12.7)
Been diagnosed with: Yes 174(44.3)
i) Pneumonia No 219(55.7)

Yes 13(3.3)
iii) Measles No 380(96.7)

iv) HIV Yes 4(1.0)

No 389(99.0)
Illness in the past two weeks

No 171(43.5)
i) Cough Yes 222(56.5)

No 325(82.7)
iii)Vomiting Yes 68(17.3)

No 246(62.6)
iv) Loss of Appetite Yes 147(37.4)
No 274(69.7)
v) Diarrhea Yes 119(30.3)

vi) Fever No 205(52.2)

Yes 188(47.8)

Regarding food security, only 33(8.4%) of the sampled households were food secure and the rest, 91.6%,
were food insecure with; 11(2.8%) mildly food insecure, 47(12.0%) moderately food insecure and the
biggest percentage, 76.8% of the households were severely food insecure table 7.

Among the children enrolled in the study, over half were exclusively breastfed 218(55.5%). For most of the
children, other food was introduced after six months 214(54.4%). Majority of the children were reported to
be eating from their own plate 237(60.3%) whereas 156(39.7%) were eating from a family pot.  Soup
199(50.6%) and porridge 162(41.2%) were the major rst foods introduced to children at 6 months.
Majority 348(88.6%) of the children feed less than 5 times a day, with only 45(11.4%) feeding more than 4
times a day (Table 3).

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 Table 3: Nutrition and Feeding History Characteristics
Factors TOTAL n (%)
Exclusively Breastfed for 6 months Yes 218(55.5)
No 146(37.2)
Non-Response 29(7.4)

At what age was other food Introduced Less than 6 Months 179(45.6)
After 6 Months 214(54.4)

Does this Child Eat From Family Pot 156(39.7)

Own Plate 237(60.3)

Food First Introduced at 6 Months Porridge 162(41.2)

Soup 199(50.6)
Milk 27(6.9)
Others 5(1.3)

Number of Times the Child Feeds <5 Times/Day 348(88.6)

≥5 Times/Day 45(11.4)

Prevalence of Malnutrition

Of the children enrolled in the study, 126/393 (32.1%; 95% CI: 27.5% - 36.9%) were stunted, 111/393
(28.2%; 95% CI: 23.8% - 33.0%) were wasted and 127/393 (32.3%; 95% CI: 27.7% - 37.2%)were
underweight Figure (1). The prevalence for a child being any one of: stunted, wasted, or underweight
was197/393 (50.1%; 95%CI: 45.1% - 55.2%). 

Factors associated with Malnutrition

The multivariate analyses for wasting are shown in Table4. Females were less likely to be wasted
(AOR=0.56, 95% CI: 0.35-0.92, p=0.022) whereas children diagnosed with diarrhea were twice likely to be
wasted (AOR=2.03, 95% CI: 1.22-3.36) Table (4).

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 Table 4: Multivariable analyses for factors associated with Wasting
Factor Adjusted Odds P-value
Ratio
 (95% CI)
Sex of Child
Male 1.00
Female 0.56(0.35-0.92) 0.022
Number of household members between 0-
5 Years

<2 Members 1.00

>2 Members 7.63(1.27-5.48) 0.010

Water Source Piped Water 1.00

Other Water 3.02(1.74-5.25) <0.001
Sources

Diarrhoea
No 1.00
Yes 2.03(1.22-3.36) 0.006
Consume Vitamin A Rich Vegetables & Yes 1.00
Tubers
No 2.22(1.35-3.65) 0.002

Factors associated with underweight

The multivariate analyses for the underweight model are shown in Table 5. Children aged older than one
year were observed to be more than twice likely to be underweight whereas (AOR=4.29, 95% CI:1.87-9.83,
p=0.0001).

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Table 5: Multivariable analyses for factors associated with Underweight
Factor Adjusted Odds Ratio P-value
 (95% CI)
Age of Child <12 Months 1.00
≥12 Months 4.29(1.87-9.83) 0.001
No 1.00
Loss of Appetite Yes 2.66(1.62-4.37) <0.001

Child's Eating Place Family Pot 1.00

Own Plate 2.51(1.48-4.27) 0.001
Carer of Sick Child Mother 1.00
Father 0.42(0.14-1.29) 0.128
Grandmother 0.16(0.04-0.59) 0.006

Consume Vitamin A Rich Vegetables & Yes 1.00

Tubers
No 2.98(1.78-5.02) <0.001
Consume Organ Meat Yes 1.00
No 2.17(1.24-3.81) 0.007

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Socio demographic and economic factors associated with Stunting

TOTAL Stunted Not Unadjusted- P Adjusted- P

 n (%)  n (%) Stunted odds ratio value  odds ratio value 
 n (%)  (95% CI)  (95% CI)
<12 51(13.0) 7(13.7) 44(86.3) 1.00        1.00
Months
≥12 342(87.0) 119(34.8) 223(65.2) 3.35(1.47- 0.004    0.001
Months 7.68)  4.43(1.86-
10.56)
Male 199(50.6) 71(35.7) 128(64.3) 1.00 1.00

Female 194(49.4) 55(28.4) 139(71.6) 0.71(0.47- 0.12 0.72(0.45- 0.168

1.09) 1.15)
of Christian 349(88.8) 116(33.2) 233(66.8) 1.00 1.00

Others 44(11.2) 10(22.7) 34(77.3) 0.59(0.28- 0.163  0.52(0.24- 0.108

1.24) 1.15)
t Family 156(39.7) 31(19.9) 125(80.1) 1.00
pot
Own 237(60.3) 95(40.1) 142(59.9) 2.70(1.68- <0.001 2.71(1.67- 0.000
plate 4.32) 4.4)
Mud 330(84.0) 105(31.8) 225(68.2) 1.00 1.00

Bricks 63(16.0) 21(33.3) 42(66.7) 1.07(0.60- 0.813  1.44(0.74- 0.278

1.90) 2.81)
Rented 193(49.1) 81(42.0) 112(58.0) 1.00 1.00
ip
Owned 200(50.9) 45(22.5) 155(77.5) 0.40(0.26- <0.00   0.4(0.25- 0.000
0.62) 0.64)
d Yes 35(9.3) 8(22.9) 27(77.1) 1.00  1.00
No 246(62.6) 67(27.2) 179(72.8) 1.00   1.00  

Yes 147(37.4) 59(40.1) 88(59.9) 1.79(1.16- 0.008 1.81(1.09- 0.022

2.76) 3.02)
Flash 19(4.8) 4(21.1) 15(78.9) 1.00 1.00
Toilet
Open 24(6.1) 14(58.3) 10(41.7)5.25(1.33- 0.018 0.31(0.12- 0.008
Spaces 20.65) 0.8)
Pit 338(86.0) 105(31.1) 233(68.9) 1.69(0.55- 0.361 0.15(0.03- 0.016
Latrine 5.21) 0.7)

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Household food security with Stunting
TOTAL Stunted Not Unadjusted- P Adjusted- P
n (%)  n (%) Stunted odds ratio value  odds ratio value 
 n (%)  (95% CI)  (95% CI)
Food 33(8.4%) 12(36.4) 21(63.6) 1.00 1.00
Secure

Mildly 11(2.8%) 1(9.1) 10(90.9) 0.18(0.02- 0.116 0.21(0.02- 0.188

Food 1.54) 2.13)
Insecure
Moderately 47(12.0%) 14(29.8) 33(70.2) 0.74(0.29- 0.537 0.44(0.06- 0.415
Food 1.91) 3.19)
Insecure
Severely 302(76.8%) 99(32.8) 203(67.2) 0.85(0.40- 0.678 0.19(0.02- 0.123
Food 1.80) 1.55)
Insecure
No 83(21.1) 21(25.3) 62(74.7) 1.00 1.00

Rarely 98(24.9) 29(29.6) 69(70.4) 1.24(0.64- 0.52 2.11(0.91- 0.080

(once or 2.40) 4.87)
twice)
Sometimes 120(30.5) 51(42.5) 69(57.5) 2.18(1.18- 0.013 3.78(1.54- 0.004
(3-10 4.03) 9.24)
times)
Often 92(23.4) 25(27.2) 67(72.8) 1.10(0.56- 0.779 3.12(1.1- 0.032
(more than 2.16) 8.84)
10)

Rarely 108(27.5) 33(30.6) 75(69.4) 0.76(0.39- 0.419 0.26(0.07- 0.044

(once or 1.48) 0.96)
twice)
Sometimes 175(44.5) 62(35.4) 113(64.6) 0.95(0.52- 0.863 0.1(0.02- 0.002
(3-10 1.74) 0.44)
times)
Often 50(12.7) 9(18.0) 41(82.0) 0.38(0.16- 0.033 0.01(0- 0.000
(more than 0.93) 0.09)
10)

Discussion
The general objective of this study was to assess the nutritional status of children aged 6-59 months in
Jubek state, South Sudan. This study showed that the levels of stunting, wasting and underweight were
high. One in three children were likely to be stunted (32.1%), or wasted (28.2%) or underweight (32.3%).
These results are comparable to the South Sudan Demographic and Health Survey report of 2006 which
showed that 31% of the under ve children were stunted, 23% wasted and 28% underweight (31).

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However, a study conducted in Jubek State South Sudan by Jessica Wude Murye in 2014 to determine
the prevalence of iron de ciency anemia and associated factors in children aged 6-59 moths showed a
lower prevalence of wasting at 10.5% and underweight at 15.4% (32). This implies that the nutritional
status among children less than ve years could have worsened during the study period for the following
reasons; rstly, because of the famine that was reported in 2017 after Jessica’s study. Secondly, this
higher levels in our study, may also be blamed on the relatively good security status in Jubek state during
study period compared to the rest of the country’s states. A factor that has led to increase in ux of
families, internally displaced persons to the study area during data collection, increase in household
sizes/dependents, and eventually increasing household energy requirements.

Factors associated with stunting:

In this study the multivariate analysis showed that factors including children older than one year, children
who were having a symptom of loss of appetite in the past two weeks, eating from own plate, not
consuming vitamin A rich vegetables and tubers and not consuming other vegetables other than leafy
vegetables had signi cant association with stunting. It was also found that children from households
with no latrine and were defecating in open space were more likely to be stunted. Although the overall
household food insecurity was extremely high at 91.6%, its association with childhood stunting was
surprisingly not signi cant. The study also found that children who ate a limited variety of foods, and
children with acute illness within two weeks were statically associated with stunting.

Socio-demographic and economic status

Children older than 12 months were 9.9 times more likely to be stunted compared to children who were
aged less than 12 months .This nding was also found in other studies from the neighboring countries(9,
10).The most probable explanation would be that many children were no longer breast feeding above 12
months of age evidenced by a higher proportion of those who were not exclusively breastfeed at 6
months and the weaning diet being predominantly porridge.  The odds of having a child with stunting
from households who rented their houses, defecate in open spaces were higher than children from
households who owned their houses, and who had ash toilet. This nding re ects the effect of socio-
economic inequalities as a key social determinant of health and child’s nutritional status. This nding is
in line with studies from Uganda and Kenya which found association between not having land, living in a
temporally house with child’s malnutrition, respectively (36). 

Child health factors

The current study also found that children who had acute illness within two weeks of interview and who
had particularly loss of appetite were more likely to be stunted. This could be due to the complex
interaction between infection and malnutrition which results in reduced food intake, nutrient absorption,
direct or catabolic nutrient losses, and increased metabolic requirements. A study found that that acute
phase response and pro-in ammatory cytokines directly affect the bone remodeling required for
longitudinal growth (41)(11). This study also found that children with no previous history of pneumonia
Page 14/21
were more likely to be stunted compared to those who had had pneumonia. This nding is not
scienti cally plausible.  However, this may be explained by the prospective that most South Sudanese
families have misconception and confusion between pneumonia and pulmonary tuberculosis which may
have caused stigma and information bias.

Nutrition and feeding practices

In this study, children who were eating from their own plates were 2.7 times more likely to be stunted
compared to those who were eating from the family pot. This could be attributed to many factors for
example caretakers whose children were eating from their own plates might not have been adhering to
the WHO recommendations regarding the practice of responsive feeding (feed infants directly and assist
older children, feed slowly and patiently, encourage, talk to the child and maintain eye contact). Children
eating from their own plates may not complete their rations of nutrients required to maintain growth.
Studies found that children who feed themselves, eating with their hands rather than being fed by
mothers were at higher risk of persistent diarrhea and malnutrition due to unhygienic behavior of hand
washing (37). The current study also found that children who were weaned on milk were less likely to be
stunted compared to those who were rst introduced to porridge. This protective association was also
observed in other studies which showed that the porridge was found to have anti nutrient inhibitor
enzymes such as lectins, phytates which have negative effects on  the linear growth (37,38, (12, 13) (11,
12)12,13). Another study from Malawi also observed this nding by comparing stunting in children
introduced on corn- Soy porridge versus milk and found that children complemented with milk were less
likely to be stunted compared to those on soy based feeds(14).

Food security

The magnitude of food insecurity also explains the high prevalence of stunting since most households
were food insecure. The main causes of stunting include inadequate nutrition to support the rapid growth
and development of infants and young children, and frequent infections during early life. Although it was
not signi cantly associated with stunting, a study by Wilna H. from South Africa on Poverty, household
food insecurity and nutrition concluded that caregivers from community with household food insecurity
had changed their food consumption patterns to cope, resulting in compromised nutrition (15).

Factors associated with wasting:

This study revealed a strong association between male gender, households with two or more children
aged zero to ve years, not consuming vitamin A rich vegetable, diarrheal disease and households with
water sources other than piped with wasting.

Results of the current study showed that female gender was protective against wasting. The reason could
be due to the effect of cultural norms in most of the South Sudanese communities which favors female
child to male child. This is in contrary to study from Asia by Kaneta K. on gender Inequality and Severe
malnutrition among children in a remote rural area of Bangladesh that found that female children were

Page 15/21
more likely to be malnourished compared to male children (40). Studies have suggested that male
children are generally more vulnerable to early childhood disease and health problems including
malnutrition (16).

Diarrhea remains among the leading causes of mortality and morbidity in children aged less than ve
years in South Sudan. It indicates lack of basic sanitation and has a reciprocal relationship with
malnutrition. In this study, children with diarrheal disease two weeks prior to the interview were 2.3 times
wasted compared to those who had no diarrhea. The study also found that children from households
using other sources of water other than piped water were threefold at risk of wasting. These ndings were
also reported in other studies (10).

Factors associated with underweight:

This study indicated that child age, not consuming vitamin A food, acute illness and children who didn’t
consume meat were more likely to be underweight. Although it is not a reliable indicator ,underweight (low
weight for age) represents both chronic and acute malnutrition (17). The present study observed strong
association between child’s age with underweight. This nding was also reported in other studies by
Pramod Singh: factors associated with underweight and stunting among children in rural Terai of eastern
Nepal (18). Infections play a major role in the etiology of undernutrition because they result in increased
needs and high energy expenditure, lower appetite, nutrient losses due to vomiting, diarrhea, poor
digestion, mal-absorption and the utilization of nutrients and disruption of metabolic equilibrium (19). In
this study, presence of an acute illness in the last two weeks prior to data collection was the contributing
factor for all forms of malnutrition. Other studies have also con rmed this association (20, 21). The odds
of a child being underweight were high among children who didn’t consume meat. This nding was also
reported study from Uganda in study done by Joyce K. Kikafunda ,which shows that, lack of meat
consumption as a risk factor for low malnutrition (22).

Finding of this study should be cautiously interpreted since it encountered some limitations including;
being conducted in a dry season when families were preparing for planting, the effect of seasonal
variation could not be assessed since this was a cross sectional study. Also being a cross sectional study,
the cause-effect relationship couldn’t be conclusively assessed.

Conclusion
The ndings of this study indicate that malnutrition is still a serious public health problem among
children below ve years of age in Jubek state, South Sudan. This study also concludes that factors
including child’s age, house ownership, absent of toilet at home, child illness and children eating from
their own plate were associated with stunting. Whereas male gender, having more than two children aged
less than ve years, diarrheal illness and drinking non piped water were associated with wasting. Factors
like child’s age, eating from own plate and reported history of loss of appetite were cross-cutting between
underweight and stunting

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List Of Abbreviations And Acronyms
ARI                                        Acute respiratory infection                      

HFIAS                                    Household food insecurity access scale

HIV                                        Human Immunode ciency Virus

HSDP                                      Health sector development plan

IYCF                                       Infant and young child feeding practice

Kgs                                        kilograms

MRDT                                     Malaria rapid diagnostic test

MUAC                                     Mid upper arm circumference

PI                                          Principle investigator

SDs                                        Standard Deviations

SHHS                                     Sudan Household Health Survey

SOMREC                                 School of medicine research and ethics committee

TB                                         Tuberculosis

UNICEF                                  United Nations International Children’s Emergency Fund

WHO                                     World Health Organization

MOH RSS                              Ministry of Health Republic of South Sudan

Declarations
Ethics Approval and consent to participate

Ethics approval for this study and a request for waiver of obtaining informed consent were sought and
granted by Makerere University School of Medicine Research and Ethics Committee. Ethics approval was
also obtained from the MoH RSS Research Ethics Committee to conduct the study. A written informed
consent/assent was sought from the caregiver followed by a full explanation of the study objectives,
procedures, risks and bene ts. Care givers were also informed that they had rights to participate and
withdraw out of the study at any time. All the information was and will be kept con dential and used only
for the purpose of the present study.

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Consent to publish

Not Applicable.

Availability of data and materials

The original data set will be availed by the corresponding author upon request.

Competing interests

The authors declare that they have no con ict of interest.

Funding

Mama- Baby Survival PLUSS through NORHED Projects fully funded this research from the design of the
study and collection, analysis, and interpretation of data but not in writing the manuscript

Authors’ contributions

 MA, as corresponding author conceived the idea and applied for funding for this research. He led the
data collection and the manuscript writing. Prof NG, was the main supervisor who has been involved in
the whole process pertaining this work i.ie. drafting, funding, and substantively revised it. Dr. NBN, and Dr.
HC supervised and guided the corresponding auther through the process of writing the manuscript,
interpreting and analyzing the data.

Acknowledgements

Special thanks to my supervisors Prof Grace Ndeezi, Dr. Nicolette Nabukeera and Dr. Hassan Chollong for
their guidance, mentorship, patience and continuing support throughout the phases of the development
of this dissertation. I cannot thank you enough. To all the pediatricians in the Department of Pediatrics
and Child Health, I am eternally indebted to you for your support, encouragement and immense
contributions towards the success of this work and my personal growth. Finally, I thank the research
assistants. I thank my Biostatistician without whom this work would not have been possible.

Authors’ information

MAI, MBBS Juba University, MMed Pediatrics Makerere University. Lecturer at college of Medicine
University of Juba, also currently works as a pediatrician at Nimule hospital Torit state South Sudan.

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Figures

Figure 1

South Sudan Map

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Figure 2

Prevelence of malnutrition among children aged 6-59 in Jubek Stat, N=393

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